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CAD/CAM as normal procedure for foot orthotics

Discussion in 'Biomechanics, Sports and Foot orthoses' started by mike weber, Nov 3, 2009.

  1. Members do not see these Ads. Sign Up.
    Ive been doing lots of reading about cad/cam devices and the process.

    I can lots of benefits of being about to create the device in a small mill with none of the messy gips, drying time and be able to control the shape degrees of skive etc

    My question is how far are we off from this being the norm for a single prac. Making 30 or more devices a month to scan ( I beleive cast scanning seems the best fit for the way I work) get the 3d module of the foot design the device and bang out the patient walks with the new device.

    The problems that I can see or have read about is 3d scan quality, most of the mill machines seem to promote EVA which I don´t use much, cost and the use of newer techniques such as medial-laterial skive does not seem to be mentioned anywhere.

    I don´t want to take the scan and send it off to a lab, but to still be incontrol of the process.

    Is this still along way off from being a reality ?

    Before I get sent to read the cad/cam thread I have more than once but I tend to get more confused when Simon and Joe start discussing the in´s and out´s of each scan system.

    So fell free to talk down to someone who likes to turn stuff on and it works, if it doesn´t call someone to fit it.
  2. Re: cad/cam as normal procedure for orthotics

    It could be a reality for you tomorrow. There are numerous scanners, CAD systems and CNC milling machines out there that would enable you to scan, design and mill. Comes down to how big your wallet is.

    I do agree that there seems to be a gap in the market for people who want to do-it-themselves with the majority of labs at the moment holding the CAD and milling system. There are middle grounds too, for example: you could scan, send the scan to a lab and have them e-mail you the file for milling. I know what you are saying though, ultimately, I like to have control over the entire process.
  3. joejared

    joejared Active Member

    Speaking from the perspective of a supplier of such a cadcam system, 30 pair a month has a long payback on investment. As to the territorial rights when I install a client/server system, assumed is that many new clients will get installed and as the rule, not the exception, client/server sites produce at least 500 pairs per month. Practically speaking, 30 pairs is roughly 4 1/2 hours of machining time.

    Medial/lateral skives aren't really new technology (2002), although a 3rd version should be done in the next week that follows almost exactly, Dr. Kirby's documented method. My own methods were those as shown to me by one lab in Canada, and as requested by another lab in Indiana. However, I happen to be in complete agreement with you when it comes to scanners. Many of the scanners out there are little more than smokey mirrors, or of such poor quality that the results are not useful.

    OreTek is completely scalablę even in the client version. Many podiatrists will more than likely scan, look at the scan and transmiţ but they aren't limited to just that. Some of my client/server customers ask that the menu be simplified, but it's all unlocked on request on the client side. The real questioņ at least for my system, is how much is a client willing to learn?

    The scanning system is only one part of what's necessary for a cad cam based system of producing orthoses. There also needs to be supporting software that will produce the preferred styles and types of device.

    I have no intention of talking down to you on this topic. However, one obvious point needs to be made. Total control over a process should also imply the willingness to learn. Currently, the variables I use to define a foot orthotic, soft accomodative device, or cast positive, are currently at a count of 334 and growing. My most recent customer I am currently training seems to prefer EVA, but actually an EVA material of a considerably denser material. This likely will be treated differently, causing me to add a 4th material type. I learn from each person I work with and simply provide the tools for a customer to do their work, with the primary goal to be that of emulating the types and styles of devices they are already producing. This latest install is hardly a challenge, but I still have challenges to meet from prior installations, and an ever increasing demand for new things.
  4. I´m one for learning and don´t mind asking lots of questions. But it appears that I´m a far way off from having my own computer design and manufactor setup here in Sweden. I currently make my own devices 1 because of I found it a great way to improve my skills, more control over the device shape etc and costs. To ship devices to other place in Europe would just make things much too expensive in Sweden as people are not used to paying for medical care.

    The problem with making the device is lost time after work or lunch etc. Thats one of benefits I can see from this type of system. More time for other things and more specific device.

    I´ll keep reading and looking hopefully as technology improve single pod set up will come onto the market.
  5. Try these guys:
  6. Arjen

    Arjen Active Member

    You might try attending one of the following tradeshows. There are a number of podiatric foot scanners and CAM milling systems on display at each one:

    Medica, Dusseldorf Nov 19-22, 2009
    ISPO / Ortho Technik, Leipzig May 2010
  7. Bruce Williams

    Bruce Williams Well-Known Member

  8. No, I use solidworks.
    It's not a dedicated piece of software and takes a whole lot of learning, but if suddenly we discover foot orthoses should look like elephants I can create them in that form. I provided the link above for Michael as this company offers a relatively low-cost turnkey solution to what he is looking for.
  9. BMJ

    BMJ Welcome New Poster

    My company debuted a new surface forming technology for making thermoformable foot orthotics less than 1 year ago. It can be done in about 20 minutes and gives complete control to the operator. We have since made several improvements, including a stand alone scanner.

    However, this technology is still limited still by the casting method you prefer. If you subscribe to the philisophy of a foam box casting (neutral or MASS), it works great and is very simple. If you use plaster casting, it requires more steps. It is still new technology, and I am the owner of the company, so be careful:)

    If you are interested, you can see the system at: www.varifitorthotics.com

    My intent by joining the forum is not to peddle my wares, but to learn more, so I appologize for the potential breach of ediquette.
    Last edited by a moderator: Nov 10, 2009
  10. I had a look at the website lots of bells and fancy bits but not much info with nuts and bolts. I requested some more info see what it comes thru with.

    Do the mill machines produce skive devices ? There was not one picture of end products.
  11. BMJ, Can you elaborate on this from your website: "Categorization of foot in terms of arch height and foot flexibility under load". How are you measuring load/ deformation of the foot?
  12. Phil Wells

    Phil Wells Active Member


    My advice would not to worry to much about the milling - dirty and expensive job that can give more headaches than cures - and concentrate on the scanning and design technology.
    If you can capture a good 3D image of the foot, then the job starts to become possible using either a generic CAD system such as Solidworks or via a design package such as Delcam's Orthomodel (Getting closer by the day to be being an good system).
    No pre-made system will give you everything you want but will do 80%+ of designs but you do get frustrated sometimes. The main advantage being speed and ease of use.
    If you follow Simon's approach and to some extent my own, then learning a CAD package is all about time but the rewards are better - you get almost full control.
    I would then suggest sending the designed insoles to a third party for milling - all they will do is mill it and return you an exact model for you to finish.
    If you do want to mill your own then you can buy a system for approx £15K that will do poly's and EVA's.

    It will save you time in the long run but be prepared to put the effort in.

    Hope this helps

  13. thanks Phil.

    I think I need to sit down with someone who runs these systems play around with them etc. Just a little hard over here as Podiatry idea´s etc is only 3 years old in Sweden. I might have to make a trip to England to see a few systems working before I dive in with $ and from the sounds of things the big time investment.
  14. joejared

    joejared Active Member

    For most practitioners, this is pretty much accurate. Volume from a single practitioner rarely warrants the cost of a machining workstation. Group a cluster of clinics together and that changes. The majority of client systems using my scanner simply use it to replace conventional shipping of casts to laboratories but aren't restricted to just that, as it comes with a complete system. For my own business model I see the scanner and system itself as a tool to encourage loyalty to a given manufacturing lab.

    Based on your country's conversion, a complete system shipped to my newest customer including shipping will be in the £12k range, including the scanning system. Probably the best bad decision I made this year was to add compatibility to the Techno-ISEL line of routers as it eliminated the need to travel to a customer site for a turn-key installation, with the machining workstation designed specifically for orthotics, no G codes.
  15. If you watch the video, you will realise that they are not milling, they appear to be using a contact digitizer then "reversing the deformation of the pins" to create a positive model. The software presumably then directs the hardware to move some of the pins in the positive model for the "corrections". After this an orthosis "blank" is thermoformed over the pin model. Interesting approach and quick. I guess the resolution of the pins is going to be significant. What it can and can't do comes mainly down to the software. If I was working on a project like this I'd ensure that the software could deal with as many prescription /design variations as possible. I don't know who they have on board from the profession as an advisor or BMJ's background, so some of the things you or I consider as commonly performed prescription variables may or may not be possible. It is a quick way of doing it but obviously this is only producing a shell, if you wanted to put any extrinsic posting onto the device this would presumably have to be done separately from the automated system? Also, if you were making more compliant devices (what Kevin calls shank dependent) these kind of devices will need post-production grinding (posting) to their inferior surfaces too. All the more reason to include methods of intrinsic rearfoot posting, i.e. medial / lateral heel skives in my book. But extrinsic posts also change the load /deformation characteristics of the devices. Using this system you couldn't create what I call "smart shells" of varying thickness across their surfaces to manipulate the load/deformation characteristics as you can with milling or "growing".

    I still think it looks like a novel approach though which for many practitioners would be sophisticated enough to meet their needs. It's kind of like across between Amfit and the old heat and mould to the foot approach, but using a corrected weightbearing cast rather than forming it straight onto the foot. Personally, I prefer non-weightbearing capture. But I know Robeer likes that kind of thing. I guess you could do a non-weightbearing plaster of Paris cast, pour a positive and digitize the positive using this system, but it kind of defeats the object of this system which is primarily to replace the plaster phase of production. Alternatively you could use a "dolly-trolly" to bring the casting box up to the foot and create semi-weightbearing models.

    Of course this is just my opinion, I've never seen the system in operation and I'm just putting 2+2 together from the information on the website. I could be completely wrong.

    I am interested in the claim from the website regarding arch height and foot deformation due to current research interests so if you could get back to me on that BMJ either here or as a private message, that would be great.
  16. Phil, I took a look at the latest release of this recently via their website, it is improving in terms of functionality; is it improving in terms of cost? What will Orthomodel set me back these days?
  17. Got it now from the website, arch height in neutral versus arch height in relaxed stance, viz. arch (navicular) drop. Disappointed. The guys using contact digitizers in their systems are really missing a trick that could revolutionise orthosis prescription in my opinion :hammer:
  18. BMJ

    BMJ Welcome New Poster

    Good Question: Since we just launched our site a few days ago, I appologize for any confusion. I suspect there will be a few more changes.
    To answer your question: When you cast the patients foot into the casting matrix (pin mold), you can do so just like you would a foam box. Then the mold is placed in our scanner and digitized. Then the patient stands full weight onto the same mold in the same spot and this new image is digitized.
    The mold is then re-set and the process is repeated for the other foot.
    After this is done, the two images are juxtaposed over each other and key foot data is obtained...and charted. 1. Arch height 2. Arch flexibilty (calculation of the arch drop / arch height (neutral) This is then compared to population norms.
    The load is simply the person standing full weight bearding on the device. The calcuation for arch height and arch drop is coming from the images and is a volumetric standardization for each foot size, so that comparisons are useful.
    We are finding that to our surprize, many people have an imbalance in arch height and flexibility from foot to foot, and there is some anecdotal coorelation between that and knee and back pain.

  19. I guess there is no change of explaining that more is there ? Or is there a spooner pat pending ?

    I must admit I did not look closly at the video on BMJ website but there was arequest for more info which I put it so will look again closer in the future, but the Delcam system really grabbed my attention so might have to go to Birmingham(?) and check it all out.
  20. joejared

    joejared Active Member

    I don't think he's being too complicated about it. In my samples folder are 4 images my newest customer and I took during training to show the results of corrections, before and after. The axial rotation about the longitudinal axis is more visible in images 1069 (corrected) and 1070 is considerably more obvious than 1071 (corrected) and 1072. Hope this helps. For the proximal view, the line on the right foot is actually off a bit but the left foot comparison is pretty useful. The images are all high resolution and will take some time to load but considerable effort was made to make it easy to flip between the pairs of images for comparison. I believe Simon is referring to the area of the first two images in the gap area between the two lines as a point of reference.
  21. Phil Wells

    Phil Wells Active Member


    Not quite sure but no where as expensive as the full suite we use.
    The really good stuff is the development work they are putting in to automating the manufacture of TCI's - the really messed up feet. Looks very promising.

  22. mgrig

    mgrig Active Member

    Does anyone use the heel rotation option from either their lab or on their own software?

    I.e. Rotate the mold in the frontal plane in the proximal 1/3 of the scan.

    How do you think it compares to orther forms of rearfoot control? (Blake inverted, skives or just a plain rearfoot wedge)
  23. Phil Wells

    Phil Wells Active Member

    We use this method as one of our prescription variables. It is also useful for adding a more progressive rearfoot post to EVA devices i.e. the rearfoot post does not end abruptly but feathers in the device.
    It can also be used to align the orthoses cup to reduce irritation.

    I don't think it can be compared to the other methods as they all add something different to the mechanical make up of the insole - personally I use a bit of everything.
    I am currently doing Blakes on the CAD system and find that there are similarities between these 2 methods.

  24. Lawrence Bevan

    Lawrence Bevan Active Member


    Delcam is a minimum £50K with scanner and mill

    I have found overall trying to discuss cad-cam is difficult - the main designers and users are the commercial labs. Talking to them about systems that are clinic based is bit like talking to turkeys about christmas!

  25. Phil Wells

    Phil Wells Active Member


    I have got to disagree - from my perspective anyway!
    The biggest issue we have at our lab is that the practitioner does not have enough control over the design of the orthotic resulting in error= returns= cost to us.
    If practitioners were able to design there own orthoses, seeing it in real time, then were able to send it to the lab for milling only, then it would be a winning combination for us and the practitioner.
    The customer gets charged less for the product and uses the labs milling expertise and where needed, the finishing skills of the technicians. The down side being for the practitioner that they can't blame a third party for getting it wrong.

    I think this will be the way forward for a small group of practitioners who have the willingness and aptitude to take over full control over the design of their orthoses.

    It then becomes a purely financial decision.

  26. Lawrence Bevan

    Lawrence Bevan Active Member

    Hi Phil

    Glad you disagree!
    So is the mechanism of scanning, prescribing, designing and forwarding for milling possible?

  27. footdoctor

    footdoctor Active Member


    The delcam system in full can be purchased a lot cheaper than 50k.

    You could look at selecting a cheaper CNC router, this will significantly reduce the cost.

  28. Lawrence Bevan

    Lawrence Bevan Active Member


    I was replying to Simon and I know he has done some Cad work and probably needs a mill of a certain scale.

    From memory the software is the most significant part of the cost with Delcam with the mill coming in at 15K. However what price are you talking?

  29. footdoctor

    footdoctor Active Member


    I have priced 3 different systems and for cast/foam box scanner, cad software,mill software and cnc router I was looking more in the region of 32k. This is with a cnc router with a suitably large enough surface area/envelope to mill 6 pairs per run.

    At 50 k you'd probably expect a large cnc milling machine, fast and fancy but for the purpose of milling orthoses or wooden positives not necessary when on a tight budget.

    Selection will depend on the volume of orthoses that you plan to produce, the materials you plan to machine,(wooden positives or direct milled polypro) and ultimately your budget.

    All the best

  30. Lets see, here’s what I reckon you could do it for if you were willing to take the time to learn and build:
    Scanner: David scanner software http://shop.david-vision-systems.de/index.php/language/en £204.73

    + Hardware lets say £250 in total.

    Alternatively you could go for the free version of David and just buy hardware then import into Meshlab software- free http://meshlab.sourceforge.net/

    Cad/ Cam software- free for e.g. http://www.freebyte.com/cad/cadcam.htm
    Art of illusion http://www.artofillusion.org/ etc

    Milling machine- well you can find plenty of make it plans on the net, lets say £500 as liberal estimate for the parts.

    Personally, I see the future in 3d printing and hence have been heavily influenced by the reprap project (google it) I think it is possible to create a manufacturing system for less than a grand and there lies the challenge that I've set for myself for you people. A complete manufacturing package for less than £1000 uk. Can it be done? If it can, you'll be the first to know.

    In my spare time(!) I'm trying to perfect this project so that Johnny shamopodist can do this for themselves.
    "Peel me off the cross
    We don't need another saviour" -Radio ass kiss: the stuffies
  31. Phil Wells

    Phil Wells Active Member


    I am sure it is. I have seen milling machines at £2k (from china) software as per Simon FOC and scanners using the Davis system for £200.
    Realistically thought I would put a milling machine at 12K - good support, large bed and able to do EVA and PP (How much volume would you need!) and scanner at £5K.
    For me software is the big issue as they all have pro's and cons and it is a very personal choice as to what suits you.

    As ever it will come down to pounds, shilling and pence!

  32. Phil, I don't think you need a 12K miller nor a 5k scanner. I think you are looking at things from a commercial level. If we took an "average" shamop who wanted one or two pair of customs per day produced "in-house", a small scale DIY miller or two would be more than adequate. You could buy several small Roland MDX millers for 12K. As for 5K for a scanner... I could buy a NextEngine + RapidWorks for less than that. Lets face it, down time from their millers could be used to produce pre-fabs too.
  33. joejared

    joejared Active Member

    a £5k ($9k) scanner will never make it in terms of dominating the industry simply because doctors just wont buy it, as the rule. I've seen scanners come close in price, but then comes the software price tag, jacking it up another $6K, or incredibly high click charges in excess of $10.00/pair. As for routers and other CNCs, I've made various routers and cncs work, but the Techno is where it's at in terms of machining plastics and in terms of foot print. It also helps to have code for their lm628/lm629 controllers, making for a safer product.

    In terms of DIY routers, and not mentioned much is machining tolerances. It's possible to get any machine to cut plastics, but the mechanisms of motion are also crucial in terms of producing a repeatable turnkey product. I'm fully expecting the next non-turnkey installation to be substandard, simply because of its rack and pinion design for the x and y axis, and pretty much expect it wont be used for much more than positives and soft appliances.

    Of the stepper motor vs servo installations, and while I was pleasantly surprised that stepper motors would work, the interface was a rather simple g-code, not leaving much room for safety or user friendliness. I control any vintage of techno's directly, as I did for the previous, and more expensive knee mill acroloop based machines. The larger machines, such as haus, hurco and fadal generally might provide a faster production per machine, but there's really no difference in the final product, and it doesn't even compare, cost wise.

    The technos are substantially easier to maintain and repair, and also have a couple oddities in terms of their mechanics. The first thing I do when I get one is bin their $2 radial bearings and replace them with angular contact bearings, for a total cost of $30.00/machine.

    My newest state-side client/server site bought a used techno and will be up and running, scanning and machining for roughly $6.5K, at approximately 6 pairs/hour for hard shell devices, received next weekend, and ready for pickup the following weekend.

    In terms of spindles/rpm/horse power, my own machine uses a 2 1/4 HP porter cable router (formerly Hitachi m12vc), which is just barely strong enough to cut orthotics, but adequate for most of my other projects. Any machine worth its weight will have 3HP or better, and for normal running should have a minimum RPM of 14K to keep the chipload low. Of the 2 routers I've used for my own machine, the Porter cable router is definitely the better router, but not quite as strong in terms of torque.
  34. joejared

    joejared Active Member

    More commonly, the reverse is true. Most practitioners at least for my product simply use it to scan a patient's feet and ship it to the lab, replacing couriers. About the only client customers I have that take advantage of all of the features are manufacturing labs.

    What you're describing is already implemented within my own network of labs. There are basically 3 tiers of client users, from as simple as (1)scan and ship, (2)to scan design and ship, (3)to scan/design/scheduling onto 12x24" plates for machining.

    Typical costs to the end user from the state-side labs, not counting royalties:

    1) $60 to $95 per pair depending on finishing (top covers etc)
    2) approximately $20 per pair unfinished with some variances depending on material expenses
    3) $70.00 to $90.00 per plate, dependent on material expenses for 4 1/2 pair typical.

    It already is the way forward, and it always was a financial decision. That's why there isn't a scanner in every practice. For most systems out there, it fails in terms of cost benefit analysis.

    As to willingness to learn, as the rule, they're less willing than you'd expect. "Lab discretion" is pretty much a common theme on prescription forms, as is damaged casts in shipping, or poor casting, and labs are often expected to make do with what they get, which is at least ethically challenging. On a positive note, and each time I've worked with a new podiatrist, I've learned something, and newer tools and methods become available. The latest work with my Australian customer resulted in a tripod based calf stablizer, allowing the patient to relax a bit more and insuring a more relaxed and stable position. For his line of products, it'll probably be an option he gives to his customers.
  35. Chris Lawrie

    Chris Lawrie Member

    Dear All
    Allow me to introduce myself. My name is Chris Lawrie and I head Delcam's Orthotics CADCAM activities along with other Healthcare releated products. I also confess that I am a student of Phil Wells and several other Podiatrists and Lab managers worldwide, who I hope can vouch for me :)
    I am not a Podiatrist, but with your permission I would like to start contributing on this forum.
    Right now we have a lot to talk about regarding our activities most of which I am confident will be of value to this thread and the forum in general.

    You have my word (for what that is worth at present) that I will not use the forum to spam you with Delcam marketing, but I would like to send you links and thoughts which may clarify some of these discussions. is this ok?

    Initially I would like to get your feedback on our new Healthcare website which we launched last week to a limited audience (our channel). The site covers many medical related markets, but does cover custom orthotic insoles is detail. You thoughts and feedback are appreciated.

    www.delcam-healthcare.com - general medical
    www.orthotics-cadcam.com - direct to orthotic insoles
    www.orthotics-cadcam.com/releasecentre - new version of OrthoModel & OrthoMill

    These sites will be launched in the next few weeks and will expand over the coming months.

    Finally, please feel free to grill me on anything relating to CADCAM & scanners. I am an Engineer by trade (CADCAM) and my specialism is in scanning technology - I arrogantly claim to know (personally) every scanner OEM and technology, from $500K aerospace scanners through to simple desktop systems. I can even bore you with details of how these technologies work.

    Thanks for your time

    Chris Lawrie
    Healthcare Product Manager
  36. Griff

    Griff Moderator

    Hi Chris,

    Welcome aboard. I personally know very little about CADCAM related things, but look forward to reading your posts and interactions with people who do such as Simon Spooner and Joe Jared.

    When I went to your website and saw the iQube I thought Apple had spread its wings into the orthoses industry... ;)

  37. Chris Lawrie

    Chris Lawrie Member

    Thanks for the welcome note Ian.

    I'm glad you spotted the deliberate parallel...we do want to be seen as the iPod of the foot scanning world...which we hope is a good thing.
    Visit again next week and you will see more on iQube (launched last week).

    If you want to learn more CADCAM and associated business benefits / ROI etc I am happy to help. I promise not to pitch our solution, but give a general overview of our experience from our customers...easier said than done i know, but i will try to speak generally on this forum.

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